Surgery Services and Mastectomy Related Treatment This plan provides benefits for mastectomy surgery and mastectomy-related services in accordance with the Women’s Health and Cancer Rights Act of 1998 and Rhode Island General Law 27-20-29 et seq. For the member receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician, physician assistant, or an advance practice registered nurse and the patient, for: • all stages of reconstruction of the breast on which the mastectomy was performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance; • prostheses; and • treatment of physical complications at all stages of the mastectomy, including lymphedema. See the Summary of Medical Benefits for the amount you pay.
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Radiation Therapy/Chemotherapy Services This plan covers chemotherapy and radiation services. This plan covers respiratory therapy services. When respiratory services are provided in your home, as part of a home care program, durable medical equipment, supplies, and oxygen are covered as a durable medical equipment service.
Environmental Services a. Preparation of Environmental Documentation (CEQA/NEPA) including but not limited to the following: a. Initial Study b. Categorical Exemption (“CE”) c. Notice of Exemption (“▇▇▇”) d. Negative Declaration (“ND”) e. Mitigated Negative Declaration (“MND”) f. Notice of Preparation (“NOP”) g. Environmental Impact Report (“EIR”) 1. Initial Document (Screen Check/Administrative Draft) 2. Addendum 3.Supplemental 4.Subsequent 5.Programmatic 6.Project h. Notice of Completion (“NOC”) i. Notice of Availability (“NOA”) j. Notice of Determination (“NOD”) k. Notice of Intent (“NOI”) l. Notices for public meetings and hearings m. Finding of No Significant Impact (“FONSI”) n. Environmental Assessment (“EA”) o. Environmental Impact Statement (“EIS”) p. Preliminary Environmental Study Form (“PES”) q. Preliminary Environmental Analysis Report (“PEAR”) r. Response to Comments s. Mitigation Monitoring Program t. Facts and Findings and Statement of Overriding Consideration
Telemedicine Services This plan covers clinically appropriate telemedicine services when the service is provided via remote access through an on-line service or other interactive audio and video telecommunications system in accordance with R.I. General Law § 27-81-1. Clinically appropriate telemedicine services may be obtained from a network provider, and from our designated telemedicine service provider. When you seek telemedicine services from our designated telemedicine service provider, the amount you pay is listed in the Summary of Medical Benefits. When you receive a covered healthcare service from a network provider via remote access, the amount you pay depends on the covered healthcare service you receive, as indicated in the Summary of Medical Benefits. For information about telemedicine services, our designated telemedicine service provider, and how to access telemedicine services, please visit our website or contact our Customer Service Department.